Evaluation of Psychological Score and Quality of Life in Adults with Allergic Rhinitis and Assessment of Related Risk Factors.

Background
To evaluate quality of life (QoL) and psychological score in adults with allergic rhinitis (AR) and to assess the possible risk factors.


Materials and Methods
A total of 110 adult patients with a define diagnosis of AR, who were referred to an outpatient clinic of allergy and immunology, were included in this study. The modified Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was applied for the evaluation of QoL in these patients. The psychological score was also assessed, using the Esprint-15 questionnaire.


Results
In a total of 110 patients (68 women, 42 men) with the mean±SEM age of 31.92±1.03 years, nasal congestion was the most common symptom (89.1%). Fifty-one (51%) out of 110 AR patients were found to have olfactory dysfunction (OD; hyposmia, 38%; anosmia, 13%). The relationship between nasal congestion and psychological score was significant (P= 0.005). OD had a significant relationship with QoL, as well as the psychological score (P= 0.001 and P= 0.003, respectively). Furthermore, psychological score had a significant relationship with reduction in QoL and sleep impairment (r, +0.654 and r, +0.591, respectively; P< 0.001). Statistical analysis showed that 54.5% of patients had a high psychological score, which was more common in females, although gender differences were not significant.


Conclusion
Considering the increasing prevalence of AR and the significant relationship of OD and sleep impairment with QoL and psychological score, early diagnosis and treatment of AR may be important in improving QoL.


INTRODUCTION
Allergic rhinitis (AR), which is the most common form of noninfectious rhinitis, is caused by airborne allergens and is characterized by nasal mucosal inflammation, rhinorrhea, congestion, itching, sneezing, and daily changes in the sense of smell for more than 1 hour as a result of immunoglobuin E (IgE)-mediated nasal inflammation (1). Allergic rhinitis may negatively affect the social life of patients due to decreased social interaction and adverse psychological effects (2).
Additionally, AR may cause significant morbidity, creating major economic burdens, increasing sedative consumption, and disrupting sleep patterns (3,4). The impact of nasal congestion on quality of sleep has been reported in both children and adults (about 88% in children and 57% in adults) (5). As 43% of AR patients wake up feeling tired, they are exposed to a high risk of depression and anxiety (4).
Several conditions, such as sinonasal diseases, upper respiratory tract infection, trauma, and aging, may cause olfactory dysfunction (OD), which is more frequent in adults with AR, compared to healthy people (6). OD is a key contributor to decreased quality of life (QoL), which reduces the pleasure of eating and drinking and decreases social competence (7). Although the frequency of OD is 19% in population-based studies (8), its frequency is estimated at 20-40% in adults with AR (9). While nasal congestion was thought to be responsible for OD, nasal inflammation has been lately suggested as a contributor (6,10,11).
In the current study, we aimed to evaluate QoL and psychological score in adult patients with AR and to assess the possible risk factors.

MATERIALS AND METHODS
In this cross sectional survey, adult patients, aged 18-60 years, with reversible symptoms of AR, who were referred to the outpatient clinic of allergy and immunology, affiliated to Immunology, Asthma, and Allergy Research Institute (IAARI) of Tehran University of Medical Sciences (Tehran, Iran) were consecutively recruited. Considering a 95% confidential interval and precision of 3%, a total of 110 individuals were enrolled in this study. The study design was approved by the IAARI local ethics committee and research committee, and written informed consents were obtained from all the patients.
In this study, patients with 1 or more AR symptoms, such as itchy nose, rhinorrhea, repeated sneezing, and nasal congestion, were included. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines were applied for AR diagnosis (12). In this study, the exclusion criteria were as follows: 1) asthma, active rhinosinusitis, or nasal anatomic structure disorder; 2) history of steroids, antihistamines, thyroid medications, and/or antidepressants for more than 1 month before the study; 3) smoking; and 4) history of nasal surgery.
The demographic data were collected, and comorbidities were also recorded. Individuals with symptoms persisting for less than 4 days or less than 4 consecutive weeks were categorized in the intermittent AR group, while those with AR symptoms for more than 4 days per week or more than 4 consecutive weeks were classified in the persistent AR group. Finally, a total of 110 patients, who met the mentioned criteria, were included in this study. The coefficient alpha was 0.9, suggesting the high internal consistency of the items.
A trained professional physician (a pediatrician and subspecialist in immunology and allergy) completed the modified RQLQ in face-to-face interviews. The mean score of QoL was measured, based on the responses to the modified RQLQ for each individual. A mean score ≥ 3 was considered as high QoL impairment, while a mean score ≤ 3 was considered as low QoL impairment. Moreover, the integrated questions were related to the "management of rhinitis", "irritability or bad-temperedness because of rhinitis", "feeling unwell because of rhinitis", and "general health status with respect to rhinitis". A mean score of ≥ 3 was considered as a high psychological score, while a mean score of ≤ 3 was considered as a low psychological score.

DISCUSSION
The findings of the current study revealed that about half of the participants with AR had OD and high psychological scores (51% and 54.5%, respectively). In addition, the relationships between OD and QOL, OD and psychological score, and psychological score and QOL were found to be significant. Although the frequency of OD in healthy adult males was significantly higher than females (15,16), no relationship was detected between gender and OD in adults with AR (17)(18)(19). Similarly, we did not observe a significant relationship between OD and gender.
The frequency of OD seems to increase with the duration and severity of AR, especially when accompanied by rhinosinusitis (20). Rhee et al. reported a positive correlation between OD and severity of AR (21). The severity of OD was higher in perennial and persistent AR groups in comparison to those with the seasonal disease (9). Nevertheless, contradictory results were reported in a study by Moll and colleagues. In their study, OD was more common in patients with seasonal AR than those with perennial AR in the pollen season (18) In another study, the frequency of anxiety disorders and mood swings was higher in subjects with allergic diseases, compared to patients without allergies (27).
Additionally, high frequencies of anxiety and depression were found in patients with OD (28). These findings are in accordance with the results of the current study, indicating a relationship between psychological impairment and other factors, including AR class, QoL score, morning symptoms, sleep impairment, and nasal congestion.
Overall, the risk of depression is greater in women with a history of allergies (25). In a recent study, the predominant incidence of anxiety and depression was highlighted in women in both AR and non-AR groups (24).
Similar results were found in the current study in terms of psychological score in females. As the atopic state does not seem to be the only factor involved in anxiety or depression among females, it is essential to conduct further studies to better understand the genesis of psychological disorders in this subgroup of patients.
Interaction of genetic and environmental factors, such as weather conditions and local/cultural aspects, is correlated with allergic sensitization (29

CONCLUSION
In the current study, the relationship between psychological score and nasal congestion, sleep impairment, morning symptoms, and QoL was well described in 110 adult patients with AR. The association of QoL with OD and impaired taste was also documented.
These findings highlight the importance of controlling AR symptoms, as they may cause severe QoL and psychological disturbances.